Provider Demographics
NPI:1093123515
Name:FREY, LORRAINE (BAS, COM)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:FREY
Suffix:
Gender:F
Credentials:BAS, COM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51564 STAPLEFORD CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-7917
Mailing Address - Country:US
Mailing Address - Phone:574-400-5696
Mailing Address - Fax:
Practice Address - Street 1:51564 STAPLEFORD CT
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-7917
Practice Address - Country:US
Practice Address - Phone:574-400-5696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA193-C-13174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist